Apple Valley Animal Hospital

1207 Cedar Creek Grade
Winchester, VA 22602



Client Information


New Clients, you will need a Client Information, Vaccination Consent, Advance Directive and Staff Hours form filled out prior to your first appointment! 

Please forward all previous records to


 print this form button


Client Information Form

Name (required)
First Name (required)
Last Name (required)
E-Mail Address (required) :
Owners County (required)

Spouse's Name
First Name
Last Name
Address (required)
Street Address (required)
City (required)
State / Province (required)
Zip / Postal Code (required)
Home Phone
Phone TypePhone Number
Cell Phone (required)
Phone TypePhone Number (required)
Driver's License number (if you are writing a check)


Work Phone
Phone TypePhone Number
Spouse's Employer

Spouse's Work Phone
Phone TypePhone Number
Name (required)

Species (required)


If other, what kind?

Breed (required)

Sex/Spayed or Neutered (required)

Female Spayed
Male Neutered

Color (required)

Date of Birth :
(Please give any records you have for your pet to the receptionist.)
Previous Veterinarian

Other medical problems

Important - Read Carefully:
I understand payment is due when services are rendered. If emergency circumstances should arise that I do not pay my bill, I understand that I owe The Apple Valley Animal Hospital for their services. Finance charges will be charged on any unpaid balance at the rate of 2% per month (24% annually). I understand that I will be responsible for all collection fees, court costs and attorney fees, should collection procedures become necessary.
Name of Responsible Party (must be over 18 years old.) (required)

I agree that I have read all of the information provided on this form and that all of the above information I have provided is true. (required)

Yes, I agree

Date (required) :

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